Provider Demographics
NPI:1801964754
Name:JAMESON, KEITH D (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:JAMESON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2916
Mailing Address - Country:US
Mailing Address - Phone:505-438-3276
Mailing Address - Fax:505-474-8201
Practice Address - Street 1:4041 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2916
Practice Address - Country:US
Practice Address - Phone:505-438-3276
Practice Address - Fax:505-474-8201
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist